BURNS - A Comprehensive Essay

(University Examination - 15 Marks)

a) Definition

b) Immediate Care

1. Remove from source - Remove the patient from the burning agent; extinguish flames by "stop, drop, and roll"
2. Remove clothing and jewelry - All burning or smouldering clothing, rings, watches, and belts must be removed from the burned area immediately to stop ongoing thermal damage
3. Cooling - Cool the burn with room-temperature (20-25°C) running tap water for at least 10-20 minutes. This limits tissue damage, reduces pain, decreases edema, and inhibits toxin production. Ice or ice-cold water must never be used as it causes vasoconstriction, worsens tissue ischemia, and can cause hypothermia
4. Cover the wound - Cover with a clean, moist dressing or sterile sheet to prevent contamination and heat loss
5. Do not burst blisters in the prehospital phase

1. Primary Survey (ATLS protocol):
   • A - Airway: Assess for inhalation injury (singed nasal hairs, hoarseness, stridor, carbonaceous sputum). Early intubation is mandatory if airway compromise is suspected - delay can be fatal as progressive edema narrows the airway
   • B - Breathing: Administer 100% oxygen via non-rebreather mask. Check for carbon monoxide poisoning (pulse oximetry is falsely normal - obtain ABG and carboxyhemoglobin levels)
   • C - Circulation: Establish two large-bore IV lines; begin fluid resuscitation; insert Foley catheter to monitor urinary output (target: 0.5 mL/kg/hour in adults)
   • D - Disability: Assess neurological status; rule out associated head injury
   • E - Exposure: Fully expose and examine, then cover to prevent hypothermia
2. Pain management - IV opioid analgesia (morphine)
3. Tetanus prophylaxis - Burns are tetanus prone wounds
4. NG tube - For gastric decompression in major burns (ileus common)
5. Wound care - Cover with sterile moist dressings; avoid aggressive debridement in emergency setting

c) Various Degrees of Burns

First-Degree Burns (Superficial Epidermal Burns)

• Involve only the epidermis
• Appear red, dry, and painful; blanch with pressure
• No blistering
• Painful due to intact nerve endings
• Heal spontaneously within 5-7 days without scarring
• Example: mild sunburn
• NOT included in TBSA calculations for resuscitation

Second-Degree Burns (Partial-Thickness Burns)

• Involve epidermis and the superficial (papillary) dermis
• Appear wet, pink, weeping, with blisters
• Blanch with pressure; extremely painful (nerve endings exposed)
• Heal within 10-14 days with minimal scarring
• Hair follicles and sweat glands intact - allow spontaneous re-epithelialisation

• Involve epidermis and the deep (reticular) dermis
• Appear mottled pale/white or red, may not blanch
• Reduced pain sensation (partial nerve destruction)
• Healing takes >14-21 days; results in hypertrophic scarring and contracture
• Often require skin grafting

Third-Degree Burns (Full-Thickness Burns)

• Destroy all layers of skin including epidermis, entire dermis, and may involve subcutaneous fat
• Appear leathery, charred, brown, white, or cherry-red; non-blanching
• Painless - complete destruction of nerve endings
• Cannot heal spontaneously - no epithelial appendages remain
• Require excision and skin grafting

Fourth-Degree Burns

• Extend through skin into muscle, bone, or tendons
• Seen in prolonged flame exposure, electrical burns, or chemical burns
• Require complex reconstruction or amputation

d) Pathophysiology of Burns

Local Response - Jackson's Zones of Burn Injury

1. Zone of Coagulation (Central zone) - The zone of maximum damage. There is irreversible coagulative necrosis of cells due to protein denaturation. This is the non-viable central core
2. Zone of Stasis (Intermediate zone) - Surrounding the central zone. Tissue is injured but potentially salvageable. Characterized by decreased perfusion, microthrombosis, endothelial damage, and ischemia from local release of vasoconstrictors. If resuscitation is inadequate, this zone converts to the zone of coagulation (burn wound progression). This is the target for fluid resuscitation
3. Zone of Hyperaemia (Peripheral zone) - The outermost zone. Minimal injury with vasodilatation and increased blood flow due to inflammatory mediators. Tissue recovers fully within 7-10 days

Systemic Response

• Occurs in two phases:
  • Ebb/Hypodynamic Phase (first 24-72 hours): Massive release of vasoactive mediators (histamine, serotonin, prostaglandins, bradykinin, reactive oxygen species, TNF-alpha, IL-1, IL-6). This causes diffuse capillary leak syndrome - plasma proteins and fluid extravasate into the interstitium. The result is hypovolaemia, reduced cardiac output, increased systemic vascular resistance, and burn shock
  • Flow/Hyperdynamic/Hypermetabolic Phase (begins 24-72 hours post-burn): Vascular permeability decreases. Cardiac output rises to 2-3x normal. Basal metabolic rate can increase 2-3 fold. This phase can persist for months

• Immediate loss of capillary integrity causes massive oedema both at the burn wound and systemically (in burns >30% TBSA)
• Hypoproteinaemia from protein loss worsens oncotic pressure, further driving fluid out of the vascular compartment
• Haemoconcentration from plasma loss leads to increased blood viscosity and microcirculatory sludging

• Profound hypermetabolism - up to 3x basal metabolic rate
• Insulin resistance and hyperglycaemia
• Increased catecholamines and cortisol
• Muscle catabolism and negative nitrogen balance
• Impaired immunity - burns cause both innate and adaptive immune suppression

• Reduced thyroid hormones (T3, T4, TSH), reduced testosterone
• Hepatic dysfunction and elevated triglycerides/free fatty acids
• Renal impairment (acute tubular necrosis from hypovolaemia + myoglobinuria in electrical burns)
• Bowel mucosa degradation with reduced absorptive capacity
• Pulmonary dysfunction - ARDS in severe burns

e) Assessment of Body Surface Area - Rule of Nines

• Chest (anterior trunk = 18%, chest alone approx. 9%)
• Both upper extremities = 9% + 9% = 18%
• Both lower extremities = 18% + 18% = 36%
• Total given = 40% TBSA (chest + extremities, as stated in the question)

• First-degree burns are NOT counted in TBSA calculations for fluid resuscitation
• Only partial-thickness and full-thickness burns are counted
• The Rule of Nines is not accurate in children - children have proportionally larger heads (up to 21% in infants) and smaller lower limbs. The Lund and Browder chart should be used in children as it accounts for age-related variations
• An alternative quick estimate: Patient's palm (including fingers) = approximately 1% TBSA - useful for irregular or scattered burns (the "palmar method")

f) Indications for Admission

1. Partial-thickness burns >10% TBSA in adults (>5% in children or elderly)
2. Full-thickness (third-degree) burns of any size
3. Burns involving critical areas: face, eyes, ears, hands, feet, genitalia, perineum, or major joints
4. Circumferential burns of the limbs or chest (risk of compartment syndrome and respiratory compromise)
5. Electrical burns (including lightning injury) - risk of cardiac arrhythmia and deep tissue injury
6. Chemical burns - risk of systemic absorption
7. Suspected or confirmed inhalation injury
8. Burns with significant associated injuries (fractures, blast injury, head trauma)
9. Burns in patients with significant comorbidities: diabetes, immunosuppression, cardiac disease, sickle cell disease, renal failure
10. Burns at extremes of age: very young children and elderly
11. Burns where abuse or neglect is suspected - for documentation and social protection
12. Inadequate social support or inability to manage outpatient wound care
13. Circumferential burns (risk of eschar-induced compartment syndrome)

g) Fluid Management - Parkland Formula

The Parkland (Baxter) Formula

Fluid requirement in 24 hours = 4 mL × Body weight (kg) × % TBSA burned

Fluid used: Lactated Ringer's (Hartmann's) solution

Calculation for the Clinical Case:

• Weight = 70 kg
• TBSA burned = 40%
• Total fluid in 24 hours = 4 × 70 × 40 = 11,200 mL (11.2 litres) of Lactated Ringer's solution

Rate of Administration:

• First half (5,600 mL) in the first 8 hours from the time of injury (NOT from time of arrival at hospital)
• Second half (5,600 mL) over the next 16 hours

If the patient arrives late (e.g., 4 hours after burn), the entire first half must be given in the remaining 4 hours (i.e., rapidly catch up)

Monitoring:

• Urine output is the best bedside guide to adequacy of resuscitation
• Target: 0.5-1.0 mL/kg/hour in adults (35-50 mL/hour for this 70 kg patient)
• Avoid under-resuscitation (worsens burn wound progression) and over-resuscitation ("fluid creep" - causes abdominal compartment syndrome, ARDS, cerebral oedema)

Important Notes:

• Colloids (albumin, plasma) are generally withheld in the first 24 hours due to capillary leak
• After 24 hours, colloids may be added to help correct oncotic pressure
• Children require modification (add maintenance fluids; Galveston or Cincinnati formulas preferred)
• The Parkland formula gives an estimate - actual rates must be titrated to urine output and clinical response

h) Management

1. Emergency/Resuscitation Phase (0-48 hours)

• Early intubation for inhalation injury, facial burns, or progressive oedema
• 100% oxygen for carbon monoxide poisoning
• Bronchoscopy to assess airway injury

• Parkland formula as above (Lactated Ringer's)
• Monitor urine output, vital signs, CVP

• Gentle cleansing with chlorhexidine or saline
• Debridement of loose, devitalized tissue
• Application of topical antimicrobials:
  • Silver sulfadiazine (SSD) - most commonly used; broad spectrum including Pseudomonas
  • Mafenide acetate - penetrates eschar; used in deep burns; carbonic anhydrase inhibitor (watch acid-base)
  • Silver-impregnated dressings (e.g., Mepilex Ag, Aquacel Ag) - modern preferred option for partial thickness burns
• Sterile non-adherent dressings; change daily or every 48-72 hours depending on agent

• Performed in circumferential full-thickness burns of limbs (compartment syndrome) or chest (respiratory compromise)
• Longitudinal incisions through the eschar to the viable tissue on medial and lateral aspects
• Done at bedside under analgesia using electrocautery or scalpel

• IV opioids (morphine, fentanyl) for acute pain
• Ketamine - useful for procedural analgesia

• Begin early enteral nutrition within 6 hours of admission via NG tube
• High calorie, high protein diet to combat hypermetabolism and catabolism
• Estimated need: Harris-Benedict equation × 2-3 stress factor
• Vitamin C, zinc, and trace elements supplementation

• Tetanus prophylaxis
• DVT prophylaxis (compression stockings, LMWH when appropriate)
• Stress ulcer prophylaxis (H2-blockers or PPI) - "Curling's ulcer" prevention
• Antibiotics only for confirmed infection, NOT prophylactically (ABA guidelines)
• Daily monitoring of FBC, electrolytes, renal function, blood cultures, wound swabs

2. Wound Management Phase (48 hours onwards)

• Gold standard surgical treatment for deep partial-thickness and full-thickness burns
• Performed within 3-5 days of injury (before infection establishes)
• Advantages: reduced infection, reduced blood loss, shorter hospital stay, better functional outcomes
• Technique: sequential tangential shaving of necrotic eschar until viable bleeding tissue is reached

• Split-thickness skin graft (STSG) from donor site (thigh, back) - most common
• Mesh grafting (expanded 1:1.5 or 1:3 ratio) for larger surface areas
• Sheet grafting for cosmetically important areas (face, hands)
• Dermal substitutes (Integra, Biobrane) for large burns where donor skin is insufficient

• Allograft (cadaveric skin) or xenograft (porcine) - for temporary wound coverage while awaiting definitive grafting in very large burns

3. Rehabilitation Phase

• Splinting and positioning to prevent contractures from day one
• Physiotherapy - passive and active exercises, early mobilisation
• Pressure garments (worn for 12-18 months) to reduce hypertrophic scarring
• Silicone gel sheets for scar management
• Psychological support - burns cause significant psychological trauma (PTSD, depression, body image issues)
• Occupational therapy - return to activities of daily living
• Reconstructive procedures for contractures (Z-plasty, skin grafts, flaps)

i) Complications of Burns

Early Complications (First few days to weeks)

1. Hypovolaemic/Burn Shock - Massive fluid loss from capillary leak; occurs within first 24-48 hours; can cause multi-organ failure if untreated
2. Inhalation Injury - Carbon monoxide poisoning (COHb >20% causes neurological symptoms), upper airway thermal burns causing obstruction, lower airway injury from toxic gases causing chemical tracheobronchitis and ARDS
3. Carbon Monoxide Poisoning - CO has 240x greater affinity for haemoglobin than oxygen; causes tissue hypoxia; pulse oximetry reads falsely normal; treat with 100% oxygen
4. Respiratory Failure / ARDS - Especially with inhalation injury and massive burns; inflammatory mediator-driven pulmonary oedema
5. Acute Kidney Injury (AKI) - From hypovolaemia, myoglobinuria (rhabdomyolysis in electrical burns and deep tissue destruction); requires forced alkaline diuresis in electrical burns
6. Burn Wound Sepsis - Leading cause of death in burns after the first 48 hours; typically from Pseudomonas aeruginosa, Staphylococcus aureus, Klebsiella; systemic sepsis can progress to septic shock and multi-organ dysfunction
7. Curling's Ulcer - Stress ulcer of the duodenum due to ischaemia, catecholamine release, and mucosal breakdown; presents as GI bleeding; prevented with early enteral nutrition and PPI/H2-blockers
8. Electrolyte Imbalances - Hyponatraemia, hyperkalaemia, hypocalcaemia, hypomagnesaemia
9. Anaemia - From blood loss, haemolysis, and nutritional deficiencies
10. Hypothermia - From massive evaporative loss through burn wound; keep patient warm
11. Compartment Syndrome - In circumferential burns; requires escharotomy/fasciotomy
12. Cardiac Arrhythmias - Especially in electrical burns
13. Disseminated Intravascular Coagulopathy (DIC) - In massive burns with sepsis

Late Complications (Weeks to months/years)

1. Hypertrophic Scarring and Keloid Formation - Common, especially in deep partial and full-thickness burns; disfiguring; managed with pressure garments, silicone, intralesional steroids, laser
2. Contractures - Fibrotic shortening of healed burn wound across joints (e.g., axilla, neck, hand, popliteal fossa); cause significant functional impairment; require reconstructive surgery (Z-plasty, release and grafting)
3. Chronic Pain and Neuropathic Pain - Persistent burning, shooting, or itching sensations
4. Psychological Complications - Post-Traumatic Stress Disorder (PTSD), depression, anxiety, body dysmorphia; require long-term psychological support
5. Functional Disability - Loss of function in hands, joint contractures impair activities of daily living
6. Marjolin's Ulcer - Malignant transformation (squamous cell carcinoma) occurring in long-standing, unstable burn scars; typically arises 20-30 years after the burn
7. Heterotopic Ossification - Abnormal bone formation around joints (elbow most common), limiting mobility
8. Osteomyelitis - In full-thickness burns exposing bone
9. Anaemia - Chronic, from bone marrow suppression and nutritional deficiencies
10. Peripheral Neuropathy - "Critical illness polyneuropathy" can be a long-term sequela in patients who had prolonged critical illness during burn treatment
11. Social and Vocational Reintegration Problems - Stigma, altered appearance, loss of employment

Summary

• Rosen's Emergency Medicine: Concepts and Clinical Practice, 10th ed.
• Roberts and Hedges' Clinical Procedures in Emergency Medicine, 7th ed.
• Fischer's Mastery of Surgery, 8th ed.
• Sabiston Textbook of Surgery, Biological Basis of Modern Surgical Practice
• American Burn Association (ABA) - Advanced Burn Life Support (ABLS) Guidelines